Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Wednesday, July 19, 2006

Global warming: an inoperable truth

Here it is: It came to me yesterday, in the operating room. Surgeons are the cause of global warming.

My practice now consists entirely of helping with laparoscopic surgery, in which operations are carried out via very small incisions in the abdomen, through which long thin instruments are inserted, along with a camera with a tiny lens. In order to see what we do, the abomen is inflated with gas, which separates the abominal wall from the organs it covers. And the gas we use? Carbon dioxide, released into the air during and after the operation.

Is it coincidence that global warming is accelerating at exactly the time that such surgery is growing at expodential rates? I don't think so. In fact, I might just publish a paper on it. As Orac has shown us, there are medical journals out there that'll print it up for me.

Amazingly enough, I had the solution during the peak years of my practice, but no one listened. If I were a better marketer (buy my book, by the way) I could have saved the world.

Cholecystectomy ("chole" = bile; "cyst" = bag; "ectomy" means removal. So we're talking removal of the gallbladder) is among the -- if not at the top of the list of -- most common operations. Must be at least a million a year done on the planet. During my years in training, cholecystectomy was done through very large incisions. Over the years in practice, I began making smaller and smaller incisions, until I was able to remove most gallbladders through a single one-inch (ok, occasionally one and a half; rarely two) incision. It was around the time I got that small (surgically speaking) that laparoscopic surgery came around, and revolutionized the operating room. I'm the first (well, the fify-thousandth) to admit it's been a good thing and that many operations are much better when done laparoscopically. Cholecystectomy, in my less than humble opinion, ain't one of them. Assuming all the surgeons doing it could be equally well taught to do it "mini" instead. In brief, mini-cholecystectomy, the way I did it, achieves the same results in terms of pain, time of discharge, and return to work. I did the extreme majority as outpatient procedures. The main difference: cost. To the tune of a couple of grand per.

There was a great study done a few years back in England. Natch. In it, neither the patient nor the surgeon knew ahead of time whether the operation would be a "lap chole" or a "mini chole." After the patient was asleep, he/she was randomized to get one or the other; a large bandage was slapped on everyone, hiding whether there was one mini-incision, or the four or five port-holes of laparoscopy. Not the patient, the recovery room nurses, or the floor nurses knew which had been done. The patient was given ad-lib pain medication, and ad-lib discharge, ad-lib return to work. No difference. Except in cost, signigicantly favoring mini-surgery. And get this: the typical "mini" incision over there, for the study, was 5-7 centimeters (2-3 inches), as opposed to my smaller ones. (Actually I'm pretty sure it was 7-10 cm, but I'm too lazy to look it up. In any case, the incisions were bigger than mine, which means if my patients had been in the study, maybe [can't say] the pain scores would have actually favored the mini.)

For a variety of reasons, I lost the war. Surgeons don't want to learn the mini-operation (it's harder than lap-chole). Outside of my area and a couple of others, patients don't hear about it, while lots of companies make wonderfully engineered equipment and make lots of bucks selling it for laparoscopy. It's beautiful stuff, no doubt about it, even if it costs a bucketload and gets to the landfill after use. So of the half-million or more gallbladder operations done every year in the US, nearly all are done with the scope. And carbon dioxide. Leaking into the atmosphere.

The list of abdominal operations done laparoscopically grows: hernias, appendectomy, colon resection, pancreas surgery, etc, etc. The jury, as it were, is still out on whether it's actually an improvement in many of those instances. My opinion: it's clearly better for hiatal hernia repair and for gastric banding for weight-loss. For the others, it depends on whom you read, and on how skillful the surgeons are at the non-laparoscopic alternatives. Don't quote me, but I'd say many operations are done laparoscopically for the same reason a dog licks his privates. But do it they do; more and more and more....

Meanwhile, gas escapes, in nearly every hospital, round the clock, round the world. The planet warms. And it's clearly the fault of me and my fellow surgeons. Sorry about that.

being a new blogger, I hate to get into conflict with my readers, so I'll be respectful, politic, diplomatic:

YM: I gather you don't believe in global warming, and think ill of Mr Gore's take on it. Well, being gentle as I can, I think that anyone who denies it should be prepared to counter the arguments of the thousands of scientests around the world who have concluded otherwise. That wasn't exactly the point of my post. Nevertheless, I have to say I find it astounding that there are folks who disagree; and that they are, in general, also those who disbelieve evolution, pick and choose science (or belittle it generally), and, for unfathomable reasons, are pretty much all Republicans. Go figure.

My feeling is that people who reject science shouldn't be allowed to have it both ways: no global warming -- no antibiotics for you. No evolution -- no herceptin. But I digress. For now, thanks for visiting. Come again.

beajerry: I love having nurses visit. And I think I'll have to factor in the hot air as you suggest. It's a paper begging to be written.

Dr. Schwab, I'd be interested to know what the average weight of your patient population was, when you were performing your "mini" open cholecystectomies. You see, we younger surgeons have to deal with a "heftier" patient population - 2/3 of Americans are overweight. For female patient's especially, one and a half inches does not even get you to the fascia.

I did my mini up to a couple of years ago: same patients as you. The one-inchers were on people not too overweight (as you know, the average gallbladder patient has always been above average in weight). The really heavy sometimes need a two-incher. But one and half was usually adequate for the pretty heavy. How? Another post, maybe. But for now: a headlight; 3/4" deavers and malleables, long instruments. Well-placed 4x8s. It isn't easy, but it can be done. Trust me: I'm a doctor

The fact that the globe is warming is not the issue. No one denies that the globe is warming. It's the cause of the warming that is at issue: human activities vs normal cyclic events. I believe the latter. You know, the ice caps on Mars are melting, and to my knowledge we (humans) arn't there - yet.

"Believe" is the operative word. Belief is what you apply to areas where facts are not available. If you "believe" it's just a cycle and man has nothing to do with it, I'll assume you've reviewed the work of climatologists around the world, essentially all of whom have agreed that activity of man is responsible for the very rapid changes of the last few decades, and have found the flaws. Your mars analogy is like saying, well, no one blew up a dam when Mississipi flooded, so when I blew up Hoover dam, the flood wasn't my fault. But hey: this is a surgeonsblog. What do I know?

To bring this thread to an end, I submit this, my final comment, on this issue:

In keeping with the theme of this BLOG, and your initial comment, consider this: in the 1970’s many of the things we have grown to dislike in our chosen fields began to appear: increasing malpractice claims, larger and larger awards, increases in the cost of insurance coverage, decreasing reimbursements from third party payers, more regulation, more paper work, higher costs for us and for our patients in order for us to care for them, loss of control, and forcing our profession to become a business rather than a calling; to name a few. A review of the medical literature also shows that starting at that time there was an explosive growth of endoscopic procedures, and the subsequent demise of your “mini cholecystectomy”.

It is my professional, medical, opinion that; based on the facts; that the cause of all our practice woes is the unimpeded, proliferation of endoscopic procedures. What shall we do? Perhaps I’ll make a movie.

As ludicrous as the fore going is, it is the same logic applied to global warming vis-à-vis man’s carbon dioxide production. With little argument, you could convince me that our CO2 production may be a hastening factor in the warming of the globe that has been ongoing since the last ice age, but not the causative factor. If we were able to totally stop our CO2 production today, it would not stop the warming. It will continue until we enter the next cooling cycle. It is grandiose ideation to believe we can alter the evolution of the earth by our presence and normal activities. Key word: “normal” – a nuclear exchange or worse being not “normal”, and one exception. That is my opinion.

I will be interested in your reply, but will write no more on this issue on your BLOG.

YM: in all sincerity, I appreciate your taking the time to post again at length. I think I hear where you are coming from, and I respect your right to disagree. The only thing I'd add is this: we, in medicine, are heirs to the scientific method. It's not always right, but by definition, it's ultimately self-correcting. Science is a way of doing things: proposing ideas, testing them, subjecting them to peer review. Etc. If we want to propose that laparoscopy is in fact the root of all evil, we have only to set up experiments by which we can prove it or disprove it. Make predictions. See if they are borne out. So, unfortunatley, I'm guess my proposal in the meat of this post would ultimately be found wanting.

The point is that global warming as related to CO2 production has been subjected to science. Predictions have been made; experiments done. It's been looked at by scientests around the world, with no axe to grind except to discover truth. And it's pretty unanimous. It's not enough, in other words, simply to say we just in a natural cycle. You have to figure the implications of the statement and subject it to rigorous testing. It's been done. I'm not a climatologist; there are authorities with infinitely greater horsepowere than me. To disbelieve them requires, as a scientest, addressing their research and exposing the flaws. Saying so, in and of itself, isn't enough.

I agree with you: that's enough on this subject. I want to think up my next surgeon-post. And truly, I do appreciate your visits and comments and hope they'll continue. Even in this thread, if you are so moved.

Through the years, I've constantly heard about all these erudite papers on cow flatulence and how that's a significant contributor to global warming. I'm not disagreeing with the added CO2 released from the OR during lap procedures (if anyone complains, just say, "Hey, at least it wasn't CO, so count your blessings.") I don't know how much bovine gas really affects the atmosphere, but it can't be too much trouble to liberally add simethicone to the hay, could it?

Better yet, since the dairy cows are already hooked up to all sorts of contraptions in little stalls, might as well shove one more hose down the exhaust pipe and use the collected gas for moving a turbine or something useful. I'm just sayin'...

Dr Schwab, you are correct. We surgeons are a major cause of global warming, but not for the reason you suggest. The CO2 that we use during our procedures is not "new" gas that otherwise would not exist, it is condensed out of the atmosphere and thus represents only an anti-entropic rearrangement of the previous status quo. The reason that it's all our fault is that our patients are all CO2 producing machines. As long as they live, they exhale CO2 with every breath. Every time we do something to a patient that prolongs his life, we aggravate the CO2 excess that is allegedly ruining Gaia. I hope that makes you feel better. We should stop doing surgery, let everyone die early, and life will be better, or at least cooler, for the rest of us.

BTW, I agree with yo mama. Global warming is always occurring, except when it isn't. Then it's global cooling. Just like the warming that occurs almost every day from about 6 am to 6 pm. Then it cools off for a while, until it warms up again. You could look it up.

I don't think you should be concerned too much about laparoscopy. I am a chemical engineer. AFAIK, CO2 is not manufactured by burning any fuel. Intead, its obtained by purifying CO2-rich gases. So, if you were to stop using compressed CO2, it won't do a squat to reduce green house emissions... that CO2 would be released to the atmosphere anyways.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.